2023-2024 Phoenix Racer Emergency Consent Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Email *

Authorization to give consent for treatment *

I hereby authorize Phoenix Racer Coaches to give consent for all medical and/or surgical treatment that may be required for my child during my absence.

Required

Racer Name *

Chronic Illnesses (list or enter 'none') *

Allergies (list or enter 'none') *

Current Medications (list or enter 'none') *

Date of last Tetanus Immunization

YYYY

Dietary Needs

Other Information

Physician's Name and Phone number

Name of Parent(s)/Guardian(s) *

Phone Number of Parent(s)/Guardian(s) *

Health Insurance # / Member # / Group #

Nearest Relative and Phone number *

Acknowledgement *

If your child needs emergency medical care and you are not available to give formal consent to medical authorities, care may become unnecessarily delayed. To protect your child, leave a completed emergency consent form with your Coach or temporary guardian. In the event of a medical emergency, the form should accompany your child to the hospital/clinic so that medical treatment can be rendered.

Required

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms